{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T04:38:39Z","timestamp":1787027919487,"version":"build-2736575974"},"reference-count":40,"publisher":"MDPI AG","issue":"6","license":[{"start":{"date-parts":[[2021,5,29]],"date-time":"2021-05-29T00:00:00Z","timestamp":1622246400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Diagnostics"],"abstract":"<jats:p>Diabetic ketoacidosis (DKA) is a lethal acute hyperglycemic complication of diabetes mellitus (DM) and it represents the initial manifestation of DM in about 15\u201320% of cases in adults and about 30\u201340% of cases in children. Postmortem diagnosis of DKA can only be made by applying thanatochemistry. Biochemistry applied postmortem is viewed with skepticism by many practitioners in the forensic field, completely lacking in many forensic services around the world, and especially in the national ones. This article aims to underline the importance of the postmortem application of biochemistry by reviewing the case of a person in the third decade of life who died suddenly at home due to diabetic ketoacidosis (DKA), whose autopsy was performed at an early PMI of approximately 24 h. Routine postmortem examinations (macroscopic, anatomopathological, and toxicological) could not establish a clear cause of death. When attention was turned to biochemical determinations (i.e., determination of glycated hemoglobin, glucose and ketone bodies (acetone, beta-hydroxybutyrate) in the blood, vitreous humor, and cerebrospinal fluid), the identified values clarified the thanatogenic mechanisms by establishing the diagnosis of DKA.<\/jats:p>","DOI":"10.3390\/diagnostics11060988","type":"journal-article","created":{"date-parts":[[2021,5,31]],"date-time":"2021-05-31T00:22:15Z","timestamp":1622420535000},"page":"988","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":6,"title":["The Vital Role of Thanatochemistry in the Postmortem Diagnostic of Diabetic Ketoacidosis\u2014Case Report"],"prefix":"10.3390","volume":"11","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-1377-0034","authenticated-orcid":false,"given":"Nona","family":"Girlescu","sequence":"first","affiliation":[{"name":"Morphofunctional Sciences 1 Department, Faculty of Medicine, \u201cGrigore T. Popa\u201d University of Medicine and Pharmacy of Iasi, 700115 Iasi, Romania"},{"name":"Department of Forensic Medicine, Institute of Forensic Medicine, 700455 Iasi, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2031-0578","authenticated-orcid":false,"given":"Bogdan","family":"Stoica","sequence":"additional","affiliation":[{"name":"Department of Forensic Medicine, Institute of Forensic Medicine, 700455 Iasi, Romania"},{"name":"Morphofunctinal Science 2 Department, Faculty of Medicine, \u201cGrigore T. Popa\u201d University of Medicine and Pharmacy of Iasi, 700115 Iasi, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Iuliana","family":"Hunea","sequence":"additional","affiliation":[{"name":"Department of Forensic Medicine, Institute of Forensic Medicine, 700455 Iasi, Romania"},{"name":"Morphofunctinal Science 2 Department, Faculty of Medicine, \u201cGrigore T. Popa\u201d University of Medicine and Pharmacy of Iasi, 700115 Iasi, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Madalina","family":"Diac","sequence":"additional","affiliation":[{"name":"Department of Forensic Medicine, Institute of Forensic Medicine, 700455 Iasi, Romania"},{"name":"Forensic Science Department, Faculty of Medicine, \u201cGrigore T. Popa\u201d University of Medicine and Pharmacy of Iasi, 700115 Iasi, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Simona Irina","family":"Damian","sequence":"additional","affiliation":[{"name":"Department of Forensic Medicine, Institute of Forensic Medicine, 700455 Iasi, Romania"},{"name":"Forensic Science Department, Faculty of Medicine, \u201cGrigore T. Popa\u201d University of Medicine and Pharmacy of Iasi, 700115 Iasi, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sofia","family":"David","sequence":"additional","affiliation":[{"name":"Department of Forensic Medicine, Institute of Forensic Medicine, 700455 Iasi, Romania"},{"name":"Forensic Science Department, Faculty of Medicine, \u201cGrigore T. Popa\u201d University of Medicine and Pharmacy of Iasi, 700115 Iasi, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tatiana","family":"Iov","sequence":"additional","affiliation":[{"name":"Department of Forensic Medicine, Institute of Forensic Medicine, 700455 Iasi, Romania"},{"name":"Forensic Science Department, Faculty of Medicine, \u201cGrigore T. Popa\u201d University of Medicine and Pharmacy of Iasi, 700115 Iasi, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1516-6981","authenticated-orcid":false,"given":"Daniel","family":"Tabian","sequence":"additional","affiliation":[{"name":"Forensic Science Department, Faculty of Medicine, \u201cGrigore T. Popa\u201d University of Medicine and Pharmacy of Iasi, 700115 Iasi, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Diana","family":"Bulgaru Iliescu","sequence":"additional","affiliation":[{"name":"Department of Forensic Medicine, Institute of Forensic Medicine, 700455 Iasi, Romania"},{"name":"Forensic Science Department, Faculty of Medicine, \u201cGrigore T. Popa\u201d University of Medicine and Pharmacy of Iasi, 700115 Iasi, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2021,5,29]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1335","DOI":"10.2337\/dc09-9032","article-title":"Hyperglycemic crises in adult patients with diabetes","volume":"32","author":"Kitabchi","year":"2009","journal-title":"Diabetes Care"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"867","DOI":"10.1111\/j.1464-5491.2008.02461.x","article-title":"Ketoacidosis occurs in both Type 1 and Type 2 diabetes- a population-based study from Northern Sweden","volume":"25","author":"Wang","year":"2008","journal-title":"Diabet. Med."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"466","DOI":"10.1046\/j.1464-5491.1999.00076.x","article-title":"The British Diabetic Association Cohort Study, II: Cause-specific mortality in patients with insulintreated diabetes mellitus","volume":"16","author":"Laing","year":"1999","journal-title":"Diabet. Med."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"2384","DOI":"10.2337\/diacare.28.10.2384","article-title":"Mortality in childhood-onset type 1 diabetes","volume":"28","author":"Dahlquist","year":"2005","journal-title":"Diabetes Care"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"2439","DOI":"10.1007\/s00125-007-0824-8","article-title":"Early mortality in EURODIAB population-based cohorts of type 1 diabetes diagnosed in childhood since 1989","volume":"50","author":"Patterson","year":"2007","journal-title":"Diabetologia"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"669","DOI":"10.1001\/archinte.1997.00440270117011","article-title":"Hyperglycemic crises in urban blacks","volume":"157","author":"Umpierrez","year":"1997","journal-title":"Arch. Intern. Med."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"330","DOI":"10.1016\/j.jpeds.2012.06.058","article-title":"Diabetic ketoacidosis at diabetes onset: Still an all too common threat in youth","volume":"162","author":"Klingensmith","year":"2013","journal-title":"J. Pediatr."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"938","DOI":"10.1542\/peds.2013-2795","article-title":"Trends in the prevalence of ketoacidosis at diabetes diagnosis: The SEARCH for diabetes in youth study","volume":"133","author":"Dabelea","year":"2014","journal-title":"Pediatrics"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"921","DOI":"10.1111\/1556-4029.13360","article-title":"Armanni-Ebstein lesions in terminal hyperglycemia","volume":"62","author":"Zhou","year":"2017","journal-title":"J. Forensic Sci."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1531","DOI":"10.1111\/j.1556-4029.2011.01865.x","article-title":"How useful is basal renal tubular epithelial cell vacuolization as a marker for significant hyperglycemia at autopsy?","volume":"56","author":"Zhou","year":"2011","journal-title":"J. Forensic Sci."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"279","DOI":"10.1097\/PAF.0000000000000380","article-title":"Basal subnuclear vacuolization, Armanni-Ebstein lesions, Wischnewsky lesions, and elevated vitreous glucose and \u03b2-hydroxybuyrate: Is it hypothermia, diabetic ketoacidosis, or both?","volume":"39","author":"Tse","year":"2018","journal-title":"Am. J. Forensic Med. Pathol."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"165","DOI":"10.1097\/PAF.0000000000000248","article-title":"Gastric mucosal petechial hemorrhages (Wischnewsky lesions), hypothermia, and diabetic ketoacidosis","volume":"37","author":"Clark","year":"2016","journal-title":"Am. J. Forensic Med. Pathol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1254","DOI":"10.4081\/cp.2020.1254","article-title":"Acute Esophageal Necrosis: A Rare Case of Upper Gastrointestinal Bleeding from Diabetic Ketoacidosis","volume":"10","author":"Uhlenhopp","year":"2020","journal-title":"Clin. Pract."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"187","DOI":"10.1007\/s00414-011-0625-y","article-title":"Postmortem chemistry update part I","volume":"126","author":"Palmiere","year":"2012","journal-title":"Int. J. Leg. Med."},{"key":"ref_15","unstructured":"Shrestha, R., Kanchan, T., and Krishan, K. (2021). Methods of Estimation of Time Since Death, StatPearls Publishing."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"181","DOI":"10.3325\/cmj.2015.56.181","article-title":"Postmortem diagnosis of diabetes mellitus and its complications","volume":"56","author":"Palmiere","year":"2015","journal-title":"Croat. Med. J."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"110235","DOI":"10.1016\/j.forsciint.2020.110235","article-title":"Vitreous humor endogenous compounds analysis for post-mortem forensic investigation","volume":"310","author":"Pigaiani","year":"2020","journal-title":"Forensic Sci. Int."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"89","DOI":"10.1016\/j.forsciint.2008.12.017","article-title":"Postmortem identification of hyperglycemia","volume":"185","author":"Zilg","year":"2009","journal-title":"Forensic Sci. Int."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"142","DOI":"10.1016\/j.forsciint.2011.07.040","article-title":"Investigation of markers to indicate and distinguish death due to Alcoholic Ketoacidosis, Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State using postmortem samples","volume":"214","author":"Hockenhull","year":"2012","journal-title":"Forensic Sci. Int."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"475","DOI":"10.1016\/j.legalmed.2015.08.004","article-title":"Comprehensive investigation of postmortem glucose levels in blood and body fluids with regard to the cause of death in forensic autopsy cases","volume":"17","author":"Chen","year":"2015","journal-title":"Leg. Med."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"161","DOI":"10.1111\/1556-4029.12265","article-title":"Postmortem distribution of 3-beta-hydroxybutyrate","volume":"59","author":"Palmiere","year":"2014","journal-title":"J. Forensic Sci."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1234","DOI":"10.1111\/j.1556-4029.2012.02121.x","article-title":"Postmortem vitreous beta-hydroxybutyrate: Interpretation in a forensic setting","volume":"57","author":"Heninger","year":"2012","journal-title":"J. Forensic Sci."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"110726","DOI":"10.1016\/j.forsciint.2021.110726","article-title":"Relationship between betahydroxybutyrate (BHB) and acetone concentrations in postmortem blood and cause of death","volume":"321","author":"Midtlyng","year":"2021","journal-title":"Forensic Sci. Int."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"293","DOI":"10.1007\/s00414-020-02343-8","article-title":"Usefulness of a blood glucose and ketone monitoring device as a screening tool for lethal diabetic ketoacidosis","volume":"135","author":"Peyron","year":"2021","journal-title":"Int. J. Leg. Med."},{"key":"ref_25","doi-asserted-by":"crossref","unstructured":"Girlescu, N., Stoica, B., Timofte, A.D., Hunea, I., Diac, M., Knieling, A., Damian, S.I., Iov, T., and Iliescu, D.B. (2021). Thanatochemical Study of Glycated Hemoglobin in Diabetic Status Assessment. Medicina, 57.","DOI":"10.3390\/medicina57040342"},{"key":"ref_26","doi-asserted-by":"crossref","unstructured":"American Diabetes Association (2013). Standards of Medical Care in Diabetes-2013. Diabetes Care, 36, S11\u2013S66.","DOI":"10.2337\/dc13-S011"},{"key":"ref_27","doi-asserted-by":"crossref","unstructured":"WHO (2011). Report of a World Health Organization consultation. Use of glycated haemoglobin (HbA1c) in the diagnosis of diabetes mellitus. Diabetes Res. Clin. Pract., 93, 299\u2013309.","DOI":"10.1016\/j.diabres.2011.03.012"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"8329","DOI":"10.1126\/scitranslmed.aay8329","article-title":"Elevated plasma \u03b2-hydroxybutyrate predicts adverse outcomes and disease progression in patients with arrhythmogenic cardiomyopathy","volume":"12","author":"Song","year":"2020","journal-title":"Sci. Transl. Med."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"91","DOI":"10.1097\/00000433-199306000-00001","article-title":"Postmortem chemistry update: Emphasis on forensic application","volume":"14","author":"Coe","year":"1993","journal-title":"Am. J. Forensic Med. Pathol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"189","DOI":"10.1097\/PAF.0b013e31825192e7","article-title":"Diabetic ketoacidosis: A silent death","volume":"33","author":"Ali","year":"2012","journal-title":"Am. J. Forensic Med. Pathol."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"275","DOI":"10.1007\/s004140050249","article-title":"Vitreous humor fructosamine concentrations in the autopsy diagnosis of diabetes mellitus","volume":"12","author":"Osuna","year":"1999","journal-title":"Int. J. Leg. Med."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"189","DOI":"10.1016\/j.forsciint.2004.09.105","article-title":"Postmortem vitreous humor \u03b2-hydroxybutyrate: Its utility for the postmortem interpretation of diabetes mellitus","volume":"153","author":"Osuna","year":"2005","journal-title":"Forensic Sci. Int."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"389","DOI":"10.1520\/JFS11684J","article-title":"Hypothermia: Autopsy findings and vitreous glucose","volume":"29","author":"Coe","year":"1984","journal-title":"J. Forensic Sci."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"1588","DOI":"10.1111\/1556-4029.14443","article-title":"Utility of Postmortem Vitreous Beta-Hydroxybutyrate Testing for Distinguishing Sudden from Prolonged Deaths and for Diagnosing Ketoacidosis","volume":"65","author":"Klaric","year":"2020","journal-title":"J. Forensic Sci."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"110418","DOI":"10.1016\/j.forsciint.2020.110418","article-title":"Postmortem diagnosis of ketoacidosis: Levels of beta-hydroxybutyrate, acetone and isopropanol in different causes of death","volume":"314","author":"Hydara","year":"2020","journal-title":"Forensic Sci. Int."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"34","DOI":"10.1016\/j.jflm.2019.02.013","article-title":"Sudden death due to diabetic ketoacidosis following power failure of an insulin pump: Autopsy and pump data","volume":"63","author":"Astrup","year":"2019","journal-title":"J. Forensic Leg. Med."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"2499","DOI":"10.1007\/s00125-018-4731-y","article-title":"Fifty years of pancreatic islet pathology in human type 1 diabetes: Insights gained and progress made","volume":"61","author":"Morgan","year":"2018","journal-title":"Diabetologia"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"627201","DOI":"10.1155\/2015\/627201","article-title":"Monitoring the modifications of the vitreous humor metabolite profile after death: An animal model","volume":"2015","author":"Rosa","year":"2015","journal-title":"Biomed. Res. Int."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"e97773","DOI":"10.1371\/journal.pone.0097773","article-title":"A metabolomic approach to animal vitreous humor topographical composition: A pilot study","volume":"9","author":"Locci","year":"2014","journal-title":"PLoS ONE"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"51","DOI":"10.3390\/metabo9030051","article-title":"PLS2 in Metabolomics","volume":"9","author":"Stocchero","year":"2019","journal-title":"Metabolites"}],"container-title":["Diagnostics"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2075-4418\/11\/6\/988\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T06:08:54Z","timestamp":1760162934000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2075-4418\/11\/6\/988"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,5,29]]},"references-count":40,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2021,6]]}},"alternative-id":["diagnostics11060988"],"URL":"https:\/\/doi.org\/10.3390\/diagnostics11060988","relation":{},"ISSN":["2075-4418"],"issn-type":[{"value":"2075-4418","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,5,29]]}}}